I. IDENTITAS KLIEN
Inisial : Tn.A (L/P) Tanggal pengkajian : 7 Februari 2023
Umur : 40 Tahun RM No. : 01
4. Riwayat Genetik:
Predisposisi: -
Presipitasi: -
5. Riwayat Nutrisi:
Predisposisi: -
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Presipitasi: -
6. Riwayat Imunisasi:
Predisposisi: -
Presipitasi: -
7. Riwayat merokok:
Predisposisi: -
Presipitasi: -
8. Riwayat alkohol:
Predisposisi:-
Presipitasi: -
9. Riwayat NAPZA:
Predisposisi: -
Presipitasi: -
B. PSIKOLOGIS
1. Konsep diri :
a. Gambaran diri : -
b. Identitas : Tn.A , laki-laki, 40 tahun, pendidikan terakhir SMA, karyawan di
perusahaan swasta dan pernah di PHK
c. Peran : .Klien sebagai suami, kepala rumah tangga dan mantan karyawan di
perusahaan swasta
d. Ideal diri :-
e. Harga diri : -
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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2. Pola asuh:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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3. Tugas perkembangan:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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4. Intelegensi:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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5. Pertahanan Psikologis:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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6. Pengalaman masa lalu:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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7. Pelaku/ Usia Korban/Usia Saksi/ Usia
a. Aniaya fisik : ……. ……. ……. ……. ……. …….
b. Aniaya seksual : ……. ……. ……. ……. ……. …….
c. Penolakan : ……. ……. ……. ……. ……. …….
d. Kekerasan dalam keluarga : ……. ……. ……. ……. ……. …….
e. Tindakan kriminal : ……. ……. ……. ……. ……. …….
f. Bullying/intimidasi: ……. ……. ……. ……. ……. …….
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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C. SOSIALKULTURAL :
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1. Riwayat pendidikan:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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2. Riwayat Pekerjaan/ ekonomi:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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3. Riwayat spiritual/keyakinan/ibadah:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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4. Riwayat budaya:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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5. Riwayat pernikahan/keluarga/tempat tinggal:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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6. Riwayat pergaulan/pertemanan/bermasyarakat:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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7. Riwayat Hospitalisasi/ pelayanan kesehatan:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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8. Riwayat afiliasi politik:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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9. Orang yang berarti: ..................................................................................................................................
10. Adakah anggota keluarga yang mengalami gangguan jiwa:.....................................................................
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11. Genogram :
= Laki-laki
= Perempuan
= Meninggal
= Klien
= Pisah
= Hidup bersama
= Garis keturunan
= Garis perkawinan
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VI. STATUS MENTAL
1. Penampilan :
Tidak rapi Penggunaan pakaian Cara berpakaian tidak seperti
Tidak sesuai biasanya
Lainnya:....................................................................................................................................................
2. Pembicaraan :
Cepat Keras Gelisah Inkoheren
Apatis Lambat Membisu Tdk mampu
memulai
pembicaraan
Lainnya:....................................................................................................................................................
3. Aktivitas motorik :
Lesu Tegang Gelisah Agitasi
Tik Grimasen Tremor Kompulsif
Lainnya:....................................................................................................................................................
4. Alam perasaan :
Sedih Ketakutan Putus asa Khawatir Gembira berlebihan
Lainnya:....................................................................................................................................................
5. Afek :
Lainnya:....................................................................................................................................................
7. Masalah Persepsi :
Pendengaran Penglihatan Perabaan
Pengecapan Penghidu
Lainnya:....................................................................................................................................................
8. Proses pikir :
Sirkumtansial Tangensial Kehilangan asosiasi
Flight of idea Blocking Pengulangan pembicaraan/perseverasi
Lainnya:....................................................................................................................................................
9. Isi pikir :
Obsesi Fobia Hipokondria
Defersonalisasi ide yang terkait Pikiran magis
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Waham
Agama Somatik Kebesaran Curiga
Nihilistic Sisip pikir Siar pikir Kontrol pikir
Lainnya:....................................................................................................................................................
10. Tingkat kesadaran:
Bingung Sedasi Stupor
Disorientasi
Waktu Tempat Orang
Lainnya:....................................................................................................................................................
11. Memori :
Gangguan daya ingat jangka panjang Gangguan daya ingat jk pendek
Gangguan daya ingat saat ini Konfabulasi
Lainnya:....................................................................................................................................................
12. Tingkat konsentrasi dan berhitung :
Mudah beralih Tidak mampu konsentrasi Tidak mampu berhitung
sederhana
Lainnya:....................................................................................................................................................
13. Kemampuan penilaian :
Gangguan ringan Gangguan bermakna
Lainnya:....................................................................................................................................................
14. Daya tilik diri :
Mengingkari penyakit yang diderita Menyalahkan hal-hal diluar dirinya
Lainnya:....................................................................................................................................................
2.BAB / BAK
Bantuan minimal Bantuan total
3.Mandi
Bantuan minimal Bantuan total
4.Berpakian / berhias
Bantuan minimal Bantuan total
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5.Istirahat dan tidur
Tidur siang, lama : …………………………………………………………………………
Tidur malam, lama : …………………………………………………………………………
6.Pengguanaan obat
Bantuan minimal Bantuan toal
7.Pemeliharaan kesehatan
Perawatan lanjutan Ya Tidak
Perawatan pendukung Ya Tidak
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ANALISA DATA
DATA MASALAH
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X. ASPEK MEDIK
Diagnosa Medik : ………………………………………………………….................…………………..
Terapi Medik :
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POHON MASALAH
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XII. KEMAMPUAN KEPERAWATAN YANG SUDAH DIMILIKI
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INTERVENSI KEPERAWATAN
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IMPLEMENTASI KEPERAWATAN
Nama perawat : Nama Klien : Ruangan :
IMPLEMENTASI TINDAKAN KEPERAWATAN EVALUASI (SOAP)
Tanggal : Jam:
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